Scottish Intercollegiate Guidelines Network 75 Epithelial ovarian cancer A national clinical guideline Introduction Screening and the role of prophylactic oophorectomy 3 Diagnosis Surgical management Chemotherapy 13 Follow up 18 Clinical trials 19 Management of malignant bowel obstruction in relapsed disease 20 Specialist palliative care 22 10 Information for patients 23 11 Implementation 25 12 Development of the guideline 26 Annexes 29 References 33 October 2003 COPIES OF ALL SIGN GUIDELINES ARE AVAILABLE BY CALLING 0131 247 3664 OR ONLINE AT WWW.SIGN.AC.UK KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS LEVELS OF EVIDENCE 1++ High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias 1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias 1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias High quality systematic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal ++ 2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal Non-analytic studies, e.g case reports, case series Expert opinion GRADES OF RECOMMENDATION Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based It does not reflect the clinical importance of the recommendation A At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++ and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ D Evidence level or 4; or Extrapolated evidence from studies rated as 2+ GOOD PRACTICE POINTS ỵ Recommended best practice based on the clinical experience of the guideline development group © Scottish Intercollegiate Guidelines Network ISBN 899893 93 First published 2003 SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland Scottish Intercollegiate Guidelines Network Royal College of Physicians Queen Street Edinburgh EH2 1JQ www.sign.ac.uk INTRODUCTION Introduction 1.1 THE NEED FOR A GUIDELINE Ovarian cancer is the fourth most frequently diagnosed cancer in women in Scotland, representing 4.6% of all newly diagnosed cancers, or around 600 new cases per year in Scotland.1 Ovarian cancer occurs as either an epithelial or a non-epithelial tumour Epithelial tumours account for over 90% of all ovarian cancers The disease is rare in girls and in women under the age of 30 years, with incidence increasing with age, reaching its maximum in the sixth decade.1 The aetiology of the disease is unknown It is more common in nulliparous women, and epidemiological studies have shown a significant reduction in ovarian cancer risk in women who have used the oral contraceptive pill Most cases of epithelial ovarian cancer are sporadic, occurring in individuals with no family history of the disease Among women in Scotland with no family history the lifetime risk of developing ovarian cancer is estimated to be in 59.3 In to 10% of women with the disease, an inherited predisposition may be a major contributory cause.4 For the majority of women with epithelial ovarian cancer standard therapy consists of surgery followed by chemotherapy Survival is dependent on the stage of cancer at initial presentation (see Annex 1) Whilst stage I disease has a five year survival rate of 85%, stage IV disease has a five year survival rate of only approximately 10%.5 Epithelial ovarian cancer is described as a ‘silent killer’ as in over 60% of cases advanced disease is found at initial presentation.6 In Scotland the overall five year survival rate is 30%, and around 400 women die from the disease per year.1 This rate has not changed significantly in the past 20 years and international comparison of five year survival rates shows that Scotland’s rate lies in the lowest quartile amongst European countries.7 Treatment is not usually curative A typical patient will develop relapsed disease requiring repeated courses of chemotherapy Relapsed disease is invariably fatal and its diagnosis has a huge impact on patients and their carers The absence of a recognisable preventable cause and of any effective screening programme means that prospects for improving survival lie with optimal management after initial presentation The goal for health professionals must be to ensure that where cure is not possible a woman can have a good quality of life with judicious use of surgery and chemotherapy 1.2 REMIT OF THE GUIDELINE This guideline is concerned with epithelial ovarian cancer only The management of borderline tumours is not included within this guideline Management requires a multidisciplinary approach that may include primary care staff, medical and clinical oncologists, gynaecologists, specialist nurses, community nurses, allied health professionals, geneticists, pathologists, specialists in laboratory medicine, pharmacists, radiologists and palliative care specialists The guideline also highlights areas of controversy as well as recommending good practice where evidence exists 1.3 DEFINITIONS The International Federation of Gynaecology and Obstetrics (FIGO) staging system used throughout this guideline is given in Annex 1.8 The histological classification of ovarian cancer is given in Annex EPITHELIAL OVARIAN CANCER 1.4 STATEMENT OF INTENT This guideline is not intended to be construed or to serve as a standard of medical care Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve These parameters of practice should be considered guidelines only Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results The ultimate judgement regarding a particular clinical procedure or treatment plan must be made by the doctor, following discussion of the options with the patient, in light of the diagnostic and treatment choices available It is advised however that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken 1.5 REVIEW AND UPDATING This guideline was issued in 2003 and will be considered for review when new evidence becomes available Any updates to the guideline in the interim period will be noted on the SIGN website: www.sign.ac.uk 2 SCREENING AND THE ROLE OF PROPHYLACTIC OOPHORECTOMY Screening and the role of prophylactic oophorectomy 2.1 INTRODUCTION At present the value of general population screening remains uncertain and cannot be recommended Results from the current UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) are not expected until 2011 Screening in the high risk population is discussed in section 2.3 2.2 IDENTIFYING WOMEN AT HIGH RISK OF DEVELOPING OVARIAN CANCER 2.2.1 DEFINING HIGH RISK GROUPS USING FAMILY HISTORY Family history can be used to define women who are at increased risk of ovarian cancer.9 Individuals at high risk are those with a first degree relative (mother, father, sister, brother, daughter or son) affected by cancer within a family that meets one of the following criteria: n n n n n n n two or more individuals with ovarian cancer, who are first degree relatives of each other one individual with ovarian cancer at any age, and one with breast cancer diagnosed under age 50 years, who are first degree relatives of each other* one relative with ovarian cancer at any age, and two with breast cancer diagnosed under 60 years, who are connected by first degree relationships* known carrier of relevant cancer gene mutations (eg BRCA or 2) untested first degree relative of a predisposing gene carrier three or more family members with colon cancer, or two with colon cancer and one with stomach, ovarian, endometrial, urinary tract or small bowel cancer in two generations One of these cancers must be diagnosed under age 50 years an individual with both breast and ovarian cancer * In these categories a second degree relative may be counted if the transmission is via the paternal line (eg a sister and a paternal aunt or a sister and two paternal aunts) ỵ 2.2.2 Women with a family history that appears to place them at high risk of developing ovarian cancer should be offered referral to a Clinical Genetics Service for assessment and confirmation of their family history They may then be eligible for referral for screening via a research trial DEFINING HIGH RISK GROUPS USING GENETIC TESTING In most cases risk estimates are based on a family history The lifetime risk estimate for individuals who have one first degree relative with ovarian cancer is two to five times the population risk.4,10 Evidence regarding the lifetime risk when an individual has more than one affected relative is sparse but this is estimated at to 23%.4,11 Two types of ovarian cancer susceptibility genes have been identified: the breast and ovarian cancer tumour suppressor genes (BRCA1 and BRCA2) and the mismatch repair genes associated with Hereditary Nonpolyposis Colorectal Cancer (HNPCC) families.12 Mutations in the BRCA1 gene are estimated to confer a 30% lifetime risk of ovarian cancer up to age 60 years and mutations in BRCA2 gene are estimated to confer an ovarian cancer risk of 27% up to age 70 years.4,13 The mismatch repair genes confer an increased lifetime risk of ovarian cancer of approximately to 12% in addition to an increased risk of endometrial cancer.14 Relatively few Scottish patients are classed as high risk from BRCA1 or BRCA2 mutations already detected in other members of the family Such highly penetrant cancer predisposing genes are estimated to account for only a small proportion, perhaps to 10% of all ovarian cancers.4 2++ 3 EPITHELIAL OVARIAN CANCER 2.2.3 REFERRAL TO CANCER GENETICS Referral rates to most UK cancer genetics centres are approximately 200 per year per million of the population.24 This is 30-fold lower than that suggested by a survey of breast cancer family history.15 General practitioners (GPs) and practice nurses are unhappy about taking responsibility for controlling access to these specialist services.16-22 Although GPs are highly selective in the cases they refer to cancer genetics clinics, over 25% of patients seen at these clinics are judged to be at low (close to population) risk.15 One randomised controlled trial (RCT) demonstrated that the provision of an education pack helped GPs to reach the correct decisions in relation to familial cancer risk The addition of faceto-face teaching sessions added no further value.23 GPs benefit from expert support from a specialist genetics service.22 Highest demand and utilisation of familial cancer services relates to breast and/or ovarian cancer.24 ỵ 2.3 Primary care clinicians should formally enquire about the woman’s family history SCREENING IN HIGH RISK GROUPS One systematic review25 and three small cohort studies26-28 suggest that presymptomatic screening by grey scale ultrasound (with or without Doppler), CA125 (see section 3.1.2), pelvic examination, or combinations of these, are not effective in detecting tumours at an early stage (see Annex 1) No clear evidence was identified as to whether screening in high risk groups has an impact on mortality from ovarian cancer D 2.4 1+, Close collaboration between primary care and specialist cancer genetics services should be developed and encouraged so that genetic cancer risk assessment can be carried out efficiently ỵ 1+, Screening for ovarian cancer in high risk groups should only be offered in the context of a research study designed to gather data on: n sensitivity and specificity of the screening tool n FIGO stages of cancers detected through screening n residual risk of primary peritoneal cancer following prophylactic oophorectomy PSYCHOLOGICAL CONSEQUENCES OF SCREENING Five case series studies29-33 and one qualitative study34 demonstrate that women with a family history of ovarian cancer who seek advice and screening may have higher levels of anxiety and depression than are found in the general population Two studies regarding the long term psychological consequences of screening in women who require surgical intervention for false positive results highlight the need for screening tools with higher specificity and the importance of incorporating support services in screening programmes.30,34 D 2.5 Screening programmes for women at increased risk of ovarian cancer should include mechanisms for providing emotional and psychological support PROPHYLACTIC OOPHORECTOMY Women identified as being at high risk of ovarian cancer can be offered prophylactic oophorectomy The decision whether or not to proceed to prophylactic oophorectomy is influenced by the fact that most women at increased risk of ovarian cancer are also at increased risk of breast cancer and there is evidence that oophorectomy reduces breast cancer risk in these cases.35 Two large cohort studies confirm the benefits of prophylactic oophorectomy for carriers of BRCA1 or BRCA2 mutations, reducing the risk of primary peritoneal carcinoma to between 0.1%36 and 0.5% per year.35 This is considerably less than the lifetime risk of ovarian cancer for those who retain their ovaries 2++ SCREENING AND THE ROLE OF PROPHYLACTIC OOPHORECTOMY Studies have shown that 2.3% of patients undergoing prophylactic oophorectomy had previously unsuspected early stage ovarian cancer.28,35 These studies also confirm the substantial reduction in breast cancer risk for mutation carriers who undergo prophylactic oophorectomy This does not appear to be abrogated by giving hormone replacement therapy (HRT) to women whose ovaries are removed before the natural menopause 2++, Women who are carriers of the BRCA1 or BRCA2 mutations should be advised that a proportion of intraperitoneal epithelial cancers arise in the Fallopian tubes so that these should be removed along with the ovaries C þ 2.5.1 Women with genetic mutations of BRCA1 or BRCA2 genes should be counselled regarding prophylactic oophorectomy and removal of Fallopian tubes at a relevant time of their life High risk women in whom mutations have not been identified should be counselled at around the age of 40 years regarding prophylactic oophorectomy QUALITY OF LIFE ISSUES One qualitative study,37 one retrospective case control study38 and one cohort study39 were identified Two of the studies report that women with BRCA1 or BRCA2 mutations regard prophylactic oophorectomy as an acceptable option for ovarian cancer risk reduction.37,39 The cohort study found that these patients not expect prophylactic oophorectomy to impair their quality of life.39 The qualitative study found that women with BRCA1 or BRCA2 mutations have strong opinions regarding the costs and benefits of prophylactic oophorectomy and that they would like more information about the physical and emotional after-effects of prophylactic oophorectomy both before, and after, surgery.37 The retrospective case control study investigated women who had chosen prophylactic oophorectomy instead of prolonged screening and suggested that these women may have more physical and emotional symptoms than women who remain on an ovarian cancer screening programme but that they report equivalent levels of cancer worry.38 3, The studies identified highlight the importance of counselling, support and information for women making a decision about prophylactic oophorectomy There is insufficient evidence to make a recommendation ỵ Women who decide to have prophylactic oophorectomy should be offered counselling, support and information before and after surgery EPITHELIAL OVARIAN CANCER Diagnosis 3.1 PRIMARY CARE 3.1.1 SIGNS AND SYMPTOMS Retrospective studies show that women with ovarian cancer present with non-specific symptoms including abdominal pain and bloating; changes in bowel habit, urinary and/or pelvic symptoms 40-42 Cachexia is uncommon and women with advanced disease often look surprisingly well Most women with ovarian cancer present with advanced disease On average, a GP will see only one new case every five years.43 No high quality evidence was identified on symptoms or signs suggestive of early ovarian cancer Patients who present with non-specific gastrointestinal symptoms may be misdiagnosed as suffering from irritable bowel syndrome 2+ 23 One descriptive study examined the impact of delayed referral from primary care on survival.44 Delay in referral was not found to be a frequent occurrence and did not impact on survival.44 ỵ 3.1.2 GPs should include ovarian cancer in the differential diagnosis when women present with recent onset persistent non-specific abdominal symptoms (including women whose abdominal and pelvic clinical examinations appear normal) BLOOD TESTS - THE ROLE OF CA125 Measurement of serum CA125 is the blood test most widely used to detect ovarian cancer CA125 is a glycoprotein antigen Elevated concentrations of CA125 are associated with malignant tumours of the pancreas, breast, lung, colon and ovary.45 Menstruation and benign conditions such as endometriosis, pelvic inflammatory disease and liver disease can also be associated with elevated concentrations of CA125.46 CA125 may also be elevated in women with ascites, pleural or pericardial effusions and in women who have had a recent laparotomy 47 Approximately 80% of patients with advanced ovarian cancer have elevated concentrations of CA125 A maximum of only 50% of patients with clinically detectable stage I disease have elevated CA125 levels.48 Despite its poor sensitivity and specificity, CA125 is most useful for detecting and monitoring non-mucinous epithelial tumours of the ovary.49 No studies were identified that assessed the usefulness of the measurement of serum CA125 in women with vague abdominal symptoms hence the guideline development group cannot recommend the routine measurement of CA125 D 3.2 Women with a pelvic mass should be referred to gynaecology irrespective of the CA125 test result SECONDARY CARE Women referred to gynaecology with suspected ovarian cancer need ultrasound assessment This will identify a pelvic mass and the presence of metastatic disease Where no obvious disease is identified the dilemma for the gynaecologist is deciding whether the pelvic mass is likely to be malignant and who should operate on the patient Prognosis in ovarian cancer correlates strongly with the ability to achieve optimal cytoreduction, which is more feasible in surgical centres with the greatest surgical experience (see section 4.4) The risk of malignancy index (RMI) scoring system can be used to predict whether the mass is malignant 3, DIAGNOSIS 3.2.1 THE RISK OF MALIGNANCY SCORING SYSTEM There are two scoring systems, RMI and RMI 2, each of which calculates scores using ultrasound features, menopausal status and preoperative CA125 level according to the equation: RMI score = ultrasound score x menopausal score x CA125 level in U/ml The original RMI scoring system and the revised RMI system are both outlined in Table 1.50,51 The RMI score gives greater weight to the ultrasound findings and menopausal status than the RMI score Table 1: The risk of malignancy index (RMI) scoring system50,51 Feature RMI Score Ultrasound features: 0= none n multilocular cyst 1= one abnormality n solid areas 3= two or more abnormalities n bilateral lesions n scites n intra-abdominal metastases RMI Score 0= none 1= one abnormality 4= two or more abnormalities Premenopausal 1 Postmenopausal CA125 U/ml U/ml RMI score = ultrasound score x menopausal score x CA125 level in U/ml Four cohort studies exploring the role of RMI scores were identified.50-53 Three of these studies compared the two RMI scores using cut-off values above 200 to indicate malignancy 51-53 The RMI score was more sensitive than the RMI system with results of 74 to 80% at a specificity of 89 to 92% and positive predictive values around 80%.51-53 2+ Other scoring methods have been used to estimate the risk of malignancy in a pelvic mass.54,55 A complex logistical regression model performed less well than the RMI scoring system.54 Colour flow and pulsed wave Doppler techniques show limited clinical application in isolation.55 C n n 3.2.2 The RMI scoring system is the method of choice for predicting whether or not an ovarian mass is likely to be malignant Women with an RMI score >200 should be referred to a centre with experience in ovarian cancer surgery VALUE OF COMPUTERISED TOMOGRAPHY (CT) AFTER ULTRASOUND The use of RMI scoring is not appropriate when obvious metastatic disease has been identified by ultrasound In this situation the gynaecologist may wish to obtain a CT scan to obtain more information on the extent of metastatic disease It is the view of the guideline development group that CT is better than US for retroperitoneal assessment, and the detection of omental and peritoneal disease If the gynaecologist wishes to assess the extent of involvement of the peritoneum, omentum and retroperitoneum prior to surgery a CT scan should be used EPITHELIAL OVARIAN CANCER Surgical management 4.1 PREPARATION FOR SURGERY 4.1.1 BOWEL PREPARATION Only a minority of ovarian cancer patients require bowel resection at the time of either primary surgery or surgery for recurrent disease One retrospective review showed incidences of colonic surgery in ovarian cancer patients of 14% and 34% for primary and secondary surgery respectively.56 A second retrospective cohort study confirmed the significantly lower incidence of infectious complications in those patients receiving preoperative bowel preparation.57 Preoperative bowel preparation for patients undergoing colorectal surgery is described in the SIGN Guideline for Colorectal Cancer.58 C 4.1.2 Preoperative bowel preparation in ovarian cancer patients should be undertaken where clinical findings and imaging reveal that advanced disease with bowel involvement is present STOMA COUNSELLING AND MARKING A poorly sited stoma due to missing or inadequate preoperative marking can lead to an awkwardly fitting appliance, with subsequent leakage, painful excoriated skin and failure of the appliance to remain secure This contributes to poor physical and psychological rehabilitation in the postoperative period Preoperative patient counselling and potential stoma site marking by a trained stoma nurse reduce the incidence of postoperative stoma complications.58-60 B 4.1.3 VENOUS THROMBOEMBOLIC PROPHYLAXIS (VTE) 1+, CA125 ESTIMATION Preoperative serum CA125 levels can be used to predict disease bulk, and may be of benefit in identifying patients in whom optimal cytoreductive surgery is feasible.64,65 CA125 levels are higher in serous rather than mucinous tumours, as well as in postmenopausal compared to premenopausal patients.66 The sensitivity and specificity of CA125 in predicting the possibility of cytoreductive surgery range from 62 to 78% and 73 to 83% respectively.64,65 It is not possible to determine if a particular preoperative CA125 level can be used to predict whether optimal cytoreduction is possible CA125 may be elevated in women who have had a recent laparotomy (see section 3.1.2) D 4.1.5 2++ Patients for whom preoperative bowel preparation is indicated should see a trained stoma nurse for counselling and potential stoma site marking Ovarian cancer patients are at significant risk of developing VTE.61 Perioperative VTE prophylaxis reduces this risk.61 Unfractionated heparin (UFH)62 or low molecular weight heparins (LMWH)63 can be used VTE prophylaxis is described in a previous SIGN Guideline.61 4.1.4 2+ 3,1- Serum CA125 levels are useful in predicting disease bulk and should be assayed preoperatively in women with pelvic masses OTHER TUMOUR MARKERS Carcinoembryonic antigen (CEA) is a tumour marker found in the blood of patients suffering from colorectal cancer There is no correlation between the CEA level and the FIGO stage of ovarian carcinoma.67 Measurement of α fetoprotein (AFP) and human chorionic gonadotropin (hCG) in younger women can help exclude non-epithelial ovarian tumours.47 D Routine preoperative CEA estimation should not be performed in patients with ovarian cancer EPITHELIAL OVARIAN CANCER 10.2 FURTHER INFORMATION FOR PATIENTS, FAMILIES AND CARERS CancerBACUP Scotland Suite 2, 3rd Floor, Cranston House, 104-114 Argyle Street, Glasgow G2 8BH Tel: 0141 223 7676, Fax: 0141 248 8422 Freephone help line available 9am to 7pm, Monday to Friday: 0808 800 1234 www.cancerbacup.org.uk Offers a free cancer information service staffed by qualified and experienced cancer nurses There are a growing number of CancerBACUP centres in hospitals and a freephone information service on all types of cancer, staffed by specialist cancer nurses Produces over 50 booklets and ‘CancerBACUP News’ three times a year Cancer Research UK PO Box 123, 61 Lincoln’s Inn Fields, London WC2A 3PX Tel: 020 7242 0200, Fax: 020 7269 3100 www.cancerresearchuk.org Macmillan Cancer Relief Scotland Osbourne House, 1-5 Osbourne Terrace, Edinburgh EH12 5HG Tel: 0131 346 5346, Fax: 0131 346 5347 Helpline: 0808 808 2020, Monday to Friday 9am to 6pm www.macmillan.org.uk A UK charity supporting people with cancer and their families with specialist information, treatment and care Maggie’s Centres Scotland The Stables, Western General Hospital, Edinburgh, EH4 2XU Tel: 0131 537 3131, Fax: 0131 537 3130 The Gatehouse, Western Infirmary, 10 Dumbarton Road, Glasgow, G11 6PA Tel: 0141 330 3311, Fax: 0141 330 3363 Email: maggies.centre@ed.ac.uk www.maggies.ed.ac.uk The goal of Maggie’s is to keep people who have cancer as healthy in mind and body as is possible, by enabling them to participate actively in the treatment of their disease Tak Tent Cancer Support Scotland Flat 5, 30 Shelley Court, Gartnavel Complex, Glasgow, G12 0YN Tel: 0141 211 0122, Fax: 0141 211 3988 Email: tak.tent@care4free.net www.taktent.org.uk Promotes the care of cancer patients, their families, friends and the staff involved professionally in cancer care by providing practical and emotional support, information, counselling and therapies as required Network of local support groups throughout Scotland The Youth Group, conTak, provides support for 16 to 25 year olds affected by cancer Ovacome Elizabeth Garrett Anderson Hospital, Huntley Street, London, WC1E 6DH Tel: 020 7380 9589 Office is staffed Monday to Friday 9am to 4pm Email: ovacome@ovacome.org.uk www.ovacome.org.uk/ A UK wide charity providing information and support for all those affected by ovarian cancer including patients, relatives, carers and health professionals Newsletter produced four times a year and fact sheets on many aspects of ovarian cancer are available on request 24 11 IMPLEMENTATION 11 Implementation The recommendations with resource implications are discussed in Annex 11.1 MANAGED CLINICAL NETWORKS Managed Clinical Networks (MCNs) are defined as: ‘linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a coordinated manner, unconstrained by existing professional and Health Board boundaries, to ensure equitable provision of high quality clinically effective services throughout Scotland.’ 178 MCNs require an administrative infrastructure so they have financial implications In the case of ovarian cancer, the core members of the MCN would be allied health professionals, gynaecological oncologists, general practitioners, laboratory medicine specialists, gynaecologists, medical and clinical oncologists, nurses, pathologists, radiologists and palliative care specialists ỵ 11.2 The health professionals involved in the care of women with ovarian cancer should be represented in a managed clinical network RECOMMENDATIONS FOR RESEARCH Surgical and chemotherapy research questions need to be answered by large randomised controlled trials Patients should be entered into appropriate clinical trials wherever possible (eg MRC, EORTC, GOG and the Scottish Gynaecological Cancer Trials Group) Seven other areas where evidence is lacking have been identified in the course of developing this guideline: Does measurement of CA125 in primary care for patients with recent onset non-specific abdominal symptoms increase the likelihood of detecting ovarian cancer? Do delayed referrals from primary care impact upon survival? Does input and support from a Clinical Nurse Specialist impact on the quality of life of patients with ovarian cancer? What is the impact on quality of life for women undergoing prophylactic surgery because of a strong family history of ovarian cancer? What are the relative effects of best supportive care versus chemotherapy in patients with relapsed disease? What is the best follow up regimen for women with ovarian cancer? Does input from a palliative medicine specialist impact upon quality of life in the management of malignant bowel obstruction? 25 EPITHELIAL OVARIAN CANCER 12 Development of the guideline 12.1 INTRODUCTION SIGN is a collaborative network of clinicians, other healthcare professionals and patient organisations, funded by NHS Quality Improvement Scotland SIGN guidelines are developed by multidisciplinary groups using a standard methodology based on a systematic review of the evidence Further details about SIGN and the guideline development methodology are contained in SIGN 50: A guideline developer’s handbook, available at www.sign.ac.uk 12.2 THE GUIDELINE DEVELOPMENT GROUP Dr Nadeem Siddiqui Chairman Dr Chris Hardwick Secretary Dr Ian Aitken Mr Andrew Anderson Mr Roger Black Ms Sandra Bredin Mrs Anne Coote Mrs Inez Crow Ms Linda Davidson Dr Heather Deans Dr Sonia Devereux Mr Craig Eriksen Dr Marie Fallon Dr Hani Gabra Professor David Hole Dr Brian Magowan Mrs Jean McAllister Dr David W M Millan Miss Kath Nattress Dr David Parkin Mr Mark Parsons Dr Denny Phillips Dr Nicholas Reed Mr Duncan Service Dr Sally Stearns Professor Michael Steele Mrs Diane Stirling Ms Joanne Topalian Dr Sara Twaddle Consultant Gynaecologist and Oncologist, Stobhill Hospital, Glasgow Specialist Registrar in Obstetrics and Gynaecology, North Glasgow Hospitals NHS Trust General Practitioner, Glasgow National Coordinator, Maggie’s Centres, Western General Hospital, Edinburgh Head, Scottish Cancer Intelligence Unit, Information and Statistics Division (ISD), Common Services Agency, Edinburgh Clinical Nurse Specialist, Stobhill Hospital, Glasgow Patient Helpline Coordinator, Argyll and Clyde Health Council, Paisley District Nurse, Falkirk Staff Nurse, Crosshouse Hospital, Kilmarnock Consultant Radiologist, Aberdeen Royal Infirmary General Practitioner, Forfar Consultant Colorectal Surgeon, Perth Royal Infirmary Senior Lecturer in Palliative Medicine, Western General Hospital, Edinburgh Consultant in Medical Oncology, Western General Hospital, Edinburgh Professor of Epidemiology and Biostatistics, West of Scotland Cancer Surveillance Unit, Department of Public Health, University of Glasgow Consultant Gynaecologist, Borders General Hospital, Melrose Principal Biochemist, North Glasgow University Hospitals NHS Trust Consultant in Pathology, Western Infirmary, Glasgow Macmillan Clinical Nurse Specialist, Western General Hospital, Edinburgh Consultant Gynaecological Oncologist, Aberdeen Royal Infirmary Principal Clinical Pharmacist, Ninewells Hospital, Dundee Consultant Gynaecologist, Perth Royal Infirmary Clinical Director, Beatson Oncology Centre, Glasgow Information Services Officer, SIGN Health Economist, Health Economics Research Unit, University of Aberdeen Professor in Medical Science, University of St Andrews Macmillan Clinical Nurse Specialist, Western General Hospital, Edinburgh Programme Manager, SIGN Health Economist, North Glasgow Hospitals NHS Trust The membership of the guideline development group was confirmed following consultation with the member organisations of SIGN Declarations of interests were made by all members of the guideline development group Further details are available from the SIGN Executive 26 12 DEVELOPMENT OF THE GUIDELINE 12.3 SYSTEMATIC LITERATURE REVIEW Literature searches were initially conducted in Medline, Embase, Cinahl, Cancerlit, and the Cochrane Library using the year range 1993-2001 The literature search was updated with new material during the course of the guideline development process Key websites on the Internet were also used, such as the National Guidelines Clearinghouse These searches were supplemented by the reference lists of relevant papers and group members’ own files The Medline version of the main search strategies can be found on the SIGN website 12.4 CONSULTATION AND PEER REVIEW 12.4.1 NATIONAL OPEN MEETING The national open meeting is the main consultative phase of SIGN guideline development, at which the guideline development group presents their draft recommendations for the first time The national open meeting for this guideline was held in June 2002 and was attended by representatives of all key specialties relevant to the guideline The draft guideline was also available on the SIGN website for a limited period at this stage to allow those unable to attend the meeting to contribute to the development of the guideline 12.4.2 SPECIALIST REVIEW SIGN is grateful to the following people for commenting on the peer review draft: Dr James Beattie Ms Helen Berrie Dr Kirsty Boyd Dr Bernard L Croall Dr Jo Davis Dr Ian Duncan Professor Ian Jacobs Professor Stan Kaye Professor Sean Kehoe Dr Harpreet Kohli Ms Ruth Payne Dr Claud Regnard Dr Terry Rollason Professor John Smyth Dr Allan Stevenson Dr Paul Symonds Director of Guideline Development, Royal College of General Practitioners (Scotland) District Nurse, Wallace Medical Centre, Falkirk Consultant in Palliative Care Medicine, The Royal Infirmary of Edinburgh Clinical Senior Lecturer, Department of Clinical Biochemistry, Grampian University Hospitals Trust, Aberdeen Consultant Gynaecologist and Oncologist, Stobhill Hospital, Glasgow Reader in Obstetrics and Gynaecology, Ninewells Hospital, Dundee Professor of Gynaecological Oncology, Director of Cancer Institute, Barts and the London Hospital, London Consultant Oncologist, Royal Marsden Hospital, London Professor of Gynaecological Cancer, Nuffield Department of Obstetrics and Gynaecology, Oxford Medical Director, Health Technology Assessment, NHS Quality Improvement Scotland Administrator, Ovacome, London Consultant in Palliative Medicine, St Oswald’s Hospice, Newcastle upon Tyne Consultant Histopathologist, Birmingham Women’s Hospital Consultant Medical Oncologist, Western General Hospital, Edinburgh Consultant Radiologist, Western General Hospital, Edinburgh Reader in Clinical Oncology, Leicester Royal Infirmary Four general practitioners were also invited to review the draft guideline but did not submit any comments 27 EPITHELIAL OVARIAN CANCER 12.5 EDITORIAL GROUP As a final quality control check, the guideline is reviewed by an Editorial Group comprising the relevant specialty representatives on SIGN Council to ensure that the peer reviewers’ comments have been addressed adequately and that any risk of bias in the guideline development process as a whole has been minimised The Editorial Group for this guideline was as follows: Mr Douglas Harper Dr Grahame Howard Professor Gordon Lowe Ms Fiona McMillan Dr Gillian Penney Dr Safia Qureshi Dr Bernice West 28 Royal College of Surgeons Royal College of Radiologists, Faculty of Oncology Chairman of SIGN, Co-editor Lead Pharmacist, North Glasgow NHS Trust Royal College of Obstetrics and Gynaecology Programme Director, SIGN, Co-editor School of Nursing and Midwifery, Faculty of Health and Social Care, The Robert Gordon University, Aberdeen ANNEXES Annex Staging carcinoma of the ovary INTERNATIONAL FEDERATION OF GYNAECOLOGY AND OBSTETRICS (FIGO) NOMENCLATURE8 Stage I - Growth limited to the ovaries Ia Growth limited to one ovary; no ascites containing malignant cells present No tumour on the external surface; capsule intact Ib Growth limited to both ovaries; no ascites containing malignant cells present No tumour on the external surfaces; capsules intact Ic *Tumour either Stage Ia or Ib, but with tumour on surface of one or both ovaries, or with capsule ruptured, or with ascites present containing malignant cells, or with positive peritoneal washings Stage II - Growth involving one or both ovaries with pelvic extension IIa Extension and/or metastases to the uterus and/or Fallopian tubes IIb Extension to other pelvic tissues IIc *Tumour either Stage IIa or IIb, but with tumour on surface of one or both ovaries; or with capsule(s) ruptured; or with ascites present containing malignant cells or with positive peritoneal washings Stage III - Tumour involving one or both ovaries with histologically confirmed peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes Superficial liver metastases equals stage III Tumour is limited to the true pelvis, but with histologically proven malignant extension to small bowel or omentum IIIa Tumour grossly limited to the true pelvis, with negative nodes, but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces, or histologically proven extension to small bowel or mesentery IIIb Tumour of one or both ovaries with histologically confirmed implants, peritoneal metastasis of abdominal peritoneal surfaces, none exceeding cm in diameter; nodes are negative IIIc Peritoneal metastasis beyond the pelvis >2 cm in diameter and/or positive retroperitoneal or inguinal nodes Stage IV Growth involving one or both ovaries with distant metastases If pleural effusion is present, there must be positive cytology to allot a case to Stage IV Parenchymal liver metastasis equals Stage IV * In order to evaluate the impact on prognosis of the different criteria for allotting cases to Stage Ic or IIc, it would be of value to know if rupture of the capsule was spontaneous, or caused by the surgeon; and if the source of malignant cells detected was peritoneal washings, or ascites 29 EPITHELIAL OVARIAN CANCER Annex Classification of ovarian cancer Ovarian neoplasms are a heterogeneous group of tumours classified according to morphological and clinical features The main subgroups are: n n n n epithelial tumours sex cord – stromal tumours germ cell tumours miscellaneous and metastatic tumours The majority of ovarian tumours (59% of all ovarian tumours and up to 90% of all primary ovarian malignancies) are epithelial Epithelial tumours can be further classified as follows: n n n n n n n n serous mucinous endometrioid mixed mesodermal / carcinosarcoma clear cell transitional cell mixed epithelial undifferentiated carcinomas The most common tumours are serous and mucinous lesions Mixed mesodermal tumours are now considered to be carcinomas with areas of sarcomatous differentiation n n n n A benign tumour has no abnormal cytological or proliferative features and no evidence of stromal invasion There is no significant malignant potential A borderline (low malignant potential or atypically proliferating) tumour is a lesion which has abnormal cytological and proliferative features within its epithelium but which has no evidence of invasion into the stromal supporting tissues Extraovarian disease can occur and these tumour deposits are referred to as implants Non-invasive implants are associated with a good prognosis Invasive implants are associated with a prognosis that is intermediate between those of benign and malignant tumours Most borderline tumours present as stage I lesions and are cured by surgery Stage by stage the overall survival of women with borderline tumours is superior to women with epithelial ovarian cancer A malignant tumour is present when there is evidence of invasion into the stromal tissues of the ovary This is usually associated with cytological atypia and increased proliferative activity Invasion is best defined as the presence of irregular spiculated or ragged epithelial islands with individual cells extending into the stromal tissues These stromal tissues can display reactive changes such as necrosis or an immature fibroblastic response These cytological and proliferative changes can occur focally within the ovarian mass An ovarian tumour must be adequately sampled for histological examination Primary peritoneal cancer is a tumour which shows similar morphological characteristics to ovarian cancer but which has no or minimal ovarian involvement GRADING OF OVARIAN CANCER There is no single universally accepted system for grading ovarian cancers Many studies have used different systems proposed either by FIGO or WHO or the American Gynecologic Oncology Group (GOG) A newly proposed grading system, based on the Nottingham system of breast cancer grading, assesses the architectural pattern of the ovarian tumour, cytological atypia and the mitotic activity within the tumour.179-181 The FIGO staging system described in Annex is a surgical staging system which does not incorporate the grade of the tumour 30 ANNEXES PSEUDOMYXOMA PERITONEI Pseudomyxoma peritonei is a clinical condition characterised by the presence of mucinous material within the peritoneal cavity This condition may originate from either the ovary or gastrointestinal tract In gynaecological pathology it is more often seen in association with borderline mucinous ovarian tumours In view of the debate about the primary site of origin of these tumours the appendix should be examined Pathological examination of the mucinous material and associated tissues should specify whether epithelial cells are present or not The cytological characteristics of the cells should also be described BRAC1 AND BRAC2 BRCA1, a gene on chromosome 17 and BRCA2, a gene on chromosome 13, increase susceptibility to breast and ovarian cancer 31 A literature review was undertaken to identify relevant economic evaluations Where these did not exist or where they were of poor quality, the recommendations were assessed by guideline development group members Guideline section Recommendation Likely resource implication 4.3.1 D To minimise the need for a second operative staging procedure, intraoperative frozen-section assessment can be used to diagnose malignancy and to exclude metastatic disease Although this service is available in some centres, there is a national shortage of pathologists Addressing the shortage of pathologists is a national issue Undertaking such work is labour intensive for technicians and histopathologists which has an opportunity cost in terms of other work which may be delayed 4.5 D Patients with stage III disease should be operated on by a gynaecological oncologist rather than a general gynaecologist or general surgeon There are major resource implications due to the UK shortage of gynaecological oncologists Addressing this shortage requires a UKwide initiative to increase the number of trainees to ensure the shortfall is met There would be associated costs of additional gynaecological oncologists including additional theatre sessions, dedicated beds, specialist nursing staff and other support staff Guidance on Commissioning Cancer Services suggests that there should be one gynaecological oncologist per 500,000 population.182 For Scotland, this implies a minimum of 11 gynaecological oncologists C 10.1 C Clinical trials should have appropriate inclusion criteria and should incorporate recognised standard treatment Clinical trials may have implications for the NHS in terms of: n new efficacious agents being identified, which require to be continued in patients participating in the trial n additional workload or opportunity costs of time foregone to treat other patients while undertaking the trial This is covered to some degree by the NHS R&D support fund These may be balanced by the provision of new therapies that would not otherwise be available to patients Patients should be offered verbal and written information throughout their journey of care and should be made aware of the support mechanisms that are in place and how to access them Structured emotional support should be available to all patients and carers More nurses with appropriate skills to provide information throughout the journey of care are required There are implications for nurse training and for services offering emotional support to patients and their families n n EPITHELIAL OVARIAN CANCER 32 Annex Resource implications of recommendations REFERENCES References 26 27 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Scottish Cancer Intelligence Unit Trends in cancer survival in Scotland 19711995 Edinburgh: Information and Statistics Division; 2000 [cited Sep 2003] Available from url: 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A comparative study of two histological prognostic features in operable breast carcinoma Histopathology 1995;27(3):219-26 NHS Executive Guidance on commissioning cancer services: improving outcomes in gynaecological cancer: the manual London: The Executive; 1999 [cited Sep 2003] Available from url: http://www.doh.gov.uk/cancer/pdfs/ gynaemanual.pdf FOLLOW UP C Symptoms of bowel obstruction can be relieved by using the following drug catagories either alone or in combination: Surgery for malignant bowel obstruction in patients with advanced ovarian cancer must be justified on the basis of achieving a significant benefit antiemetic antisecretory analgesic corticosteroids D B Patients with advanced ovarian cancer require a coordinated, multiprofessional approach with access to a specialist palliative care team C Structured emotional support should be available to all patients and carers Patients should be offered verbal and written information throughout their journey of care and should be made aware of support mechanisms in place and how to access them available to patients and carers ỵ Voluntary sector agencies can be used to expand the levels of support C INFORMATION FOR PATIENTS Patients with persistent poorly controlled symptoms should be referred to specialist palliative care SPECIALIST PALLIATIVE CARE § § § § C MANAGEMENT OF MALIGNANT BOWEL OBSTRUCTION for those patients not in trials ỵ The primary care team should be made aware of the follow up protocol local multidisciplinary specialist clinics ỵ Patients who are not in clinical trials should be followed up within t t t t SOURCES OF FURTHER INFORMATION FOR PATIENTS AND CARERS A UK wide charity providing information and support for all those affected by ovarian cancer including patients, relatives, carers and health professionals Newsletter produced four times a year and fact sheets on many aspects of ovarian cancer are available on request Ovacome Elizabeth Garrett Anderson Hospital, Huntley Street, London, WC1E 6DH Tel: 020 7380 9589 Office is staffed Monday to Friday, 9am to 4pm Email: ovacome@ovacome.org.uk www.ovacome.org.uk/ Promotes the care of cancer patients, their families, friends and the staff involved professionally in cancer care by providing practical and emotional support, information, counselling and therapies as required Network of local support groups throughout Scotland The Youth Group, conTak, provides support for 16 to 25 year olds affected by cancer Tak Tent Cancer Support Scotland Flat 5, 30 Shelley Court, Gartnavel Complex, Glasgow, G12 0YN Tel: 0141 211 0122, Fax: 0141 211 3988 Email: tak.tent@care4free.net www.taktent.org.uk The goal of Maggie’s is to keep people who have cancer as healthy in mind and body as is possible, by enabling them to participate actively in the treatment of their disease The Gatehouse, Western Infirmary, 10 Dumbarton Road, Glasgow, G11 6PA Tel: 0141 330 3311, Fax: 0141 330 3363 Email: maggies.centre@ed.ac.uk www.maggies.ed.ac.uk Maggie’s Centres Scotland The Stables, Western General Hospital, Edinburgh, EH4 2XU Tel: 0131 537 3131, Fax: 0131 537 3130 A UK charity supporting people with cancer and their families with specialist information, treatment and care Macmillan Cancer Relief Scotland Osbourne House, 1-5 Osbourne Terrace, Edinburgh EH12 5HG Tel: 0131 346 5346, Fax: 0131 346 5347 Helpline: 0808 808 2020 Monday to Friday, 9am to 6pm www.macmillan.org.uk Cancer Research UK PO Box 123, 61 Lincoln’s Inn Fields, London WC2A 3PX Tel: 020 7242 0200, Fax: 020 7269 3100 www.cancerresearchuk.org Offers a free cancer information service staffed by qualified and experienced cancer nurses There are a growing number of CancerBACUP centres in hospitals and a freephone information service on all types of cancer, staffed by specialist cancer nurses Produces over 50 booklets and ‘CancerBACUP News’ three times a year CancerBACUP Scotland Suite 2, 3rd Floor, Cranston House, 104-114 Argyle Street, Glasgow G2 8BH Tel: 0141 223 7676, Fax: 0141 248 8422 Freephone help line: 0808 800 1234 Available Monday to Friday, 9am to 7pm www.cancerbacup.org.uk t ỵ ỵ C D D ỵ ỵ ỵ t C D ỵ t C t SCREENING Women with a family history that appears to put them at high risk of developing ovarian cancer should be offered referral to a Clinical Genetics Service for assessment and confirmation of their family history They may then be eligible for referral for screening via a research trial Close collaboration between primary care and specialist cancer genetics services should be developed and encouraged so that genetic cancer risk assessment can be carried out efficiently Primary care clinicians should formally enquire about the woman’s family history Screening for ovarian cancer in high risk groups should only be offered in the context of a research study designed to gather data on: § sensitivity and specificity of the screening tool § FIGO stages of cancers detected through screening § residual risk of primary peritoneal cancer following prophylactic oophorectomy Screening programmes for women at increased risk of ovarian cancer should include mechanisms for providing emotional and psychological support Women with genetic mutations of BRCA1 or BRCA2 genes should be counselled regarding prophylactic oophorectomy and removal of Fallopian tubes at a relevant time of their life High risk women in whom mutations have not been identified should be counselled at around the age of 40 years regarding prophylactic oophorectomy Women who decide to have prophylactic oophorectomy should be offered counselling, support and information before and after surgery DIAGNOSIS GPs should include ovarian cancer in the differential diagnosis when women present with recent onset persistent non-specific abdominal symptoms (including women whose abdominal and pelvic clinical examinations appear normal) Women with a pelvic mass should be referred to gynaecology irrespective of the CA125 test result § The RMI scoring system is the method of choice for predicting whether or not an ovarian mass is likely to be malignant § Women with an RMI score >200 should be referred to a centre with experience in ovarian cancer surgery SURGERY Preoperative bowel preparation in ovarian cancer patients should be undertaken where clinical findings and imaging reveal that advanced disease with bowel involvement is present EPITHELIAL OVARIAN CANCER D D B Routine preoperative CEA estimation should not be performed in patients with ovarian cancer Serum CA125 levels are useful in predicting disease bulk and should be assayed preoperatively in women with pelvic masses Patients for whom preoperative bowel preparation is indicated should see a trained stoma nurse for counselling and potential stoma site marking SURGERY (Contd.) D § Đ Đ Đ C ỵ D Interval debulking surgery is recommended, if performance status allows, where there is evidence of response to chemotherapy as determined by CA125 and imaging In advanced disease: § bowel surgery should only be performed where obstruction is imminent or where it enables optimal cytoreduction or aggressive cytoreduction to be achieved In advanced disease: § patients with stage III disease should be operated on by a gynaecological oncologist rather than a general gynaecologist or a general surgeon In advanced disease: § if aggressive cytoreduction is not possible then optimal cytoreduction is the recommended surgical procedure if performance status allows this to take place Đ ỵ Patients should be given their diagnosis of ovarian cancer after surgery in the presence of a nurse who is a fully integrated member of the clinical team If a nurse specialist is not available this should be a dedicated named nurse or link nurse staging should be through a mid-line incision to allow palpation of all peritoneal surfaces assessment of peritoneal cytology, hysterectomy, removal of ovaries and Fallopian tubes and infracolic omentectomy should be performed capsular rupture during surgery should be avoided aim to exclude disease involving the liver, spleen, peritoneum, retroperitoneal nodes, appendix and diaphragm by close clinical inspection and palpation cases where only the ovarian cyst was removed should be discussed within the multidisciplinary team and if there is concern that there is a likelihood of metastatic disease restaging is recommended ỵ C ỵ In early disease: To minimise the need for a second operative staging procedure, intraoperative frozen section assessment can be used to diagnose malignancy and to exclude metastatic disease t Patients with ovarian cancer should have access to an appropriately trained nurse, who is an integral member of the gynaecological cancer team, throughout their journey of care CHEMOTHERAPY ỵ B Carboplatin can be offered to all early stage epithelial ovarian cancer patients In advanced disease: § first line chemotherapy treatment should include a platinum agent either in combination or as a single agent, unless specifically contraindicated § carboplatin is the platinum of choice in both single and combination therapy § paclitaxel is recommended in combination therapy with platinum in first line post-surgery treatment where the potential benefits justify the toxicity of the therapy § patients who choose less toxic therapy or who are unfit for taxanes should be offered single agent carboplatin § cyclophosphamide is not recommended in first line chemotherapy treatment § anthracyclines are not recommended in first line chemotherapy treatment outside RCTs In relapsed disease: § chemotherapy for recurrent ovarian cancer should be regarded as palliative in intent and should be reserved for symptomatic recurrence of disease § symptomatic platinum-sensitive cancer recurrence should be treated with further platinum and paclitaxel In relapsed disease: § Tamoxifen should be considered in patients for whom chemotherapy is not appropriate Women should be given accurate information on their likely response to chemotherapy, including adverse effects, so that they can make an informed decision on whether or not to proceed If erythropoetin is used to treat anaemia it should only be when the haemoglobin concentration is ≤10 g/dL and the dose should not exceed 450 units/kg/week § the optimal agents in platinum-resistant disease have yet to be defined and treatment should be based on specialist judgement § cautious clinical judgement should be used when considering the use of platinum and paclitaxel in patients with symptomatic platinum-sensitive cancer recurrence after a treatment free interval of 6-12 months D B ỵ In relapsed disease: C B A Chemotherapy for patients with disease confined to the ovaries where the tumour is well differentiated (FIGO stage 1a grade and FIGO stage 1b grade 1, see Annexes and 2), may be deferred if optimal surgery has been performed surgery ỵ Chemotherapy should be started no later than eight weeks after t 75 ... 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